Creating New Families is intended to reflect the practice of the specialist, multi-disciplinary Fostering and Adoption team in the Child and Family Department of the Tavistock Clinic. The team is firmly rooted in an approach which values inter-disciplinary working for the contribution which the thinking of each discipline makes to the overall endeavour with the child and family. It also places great importance on multi-agency collaboration, especially with social services and education, without which no intervention with this group of children can succeed. The book represents the differing ways in which members contribute to the work of the team, with individual and joint accounts by clinicians of the ways in which their therapeutic practice has evolved and about the theoretical thinking on which it is based.Contributors: Professor Lionel Hersov; Rita Harris; Sally Hodges; Sara Barratt; Miriam Steele; Hamish Canham; Laverne Antrobus; Juliet Hopkins; Margaret Rustin; Julia Granville; Louise Emanuel; and Graham Music.About the Tavistock Clinic Series:Founded in 1920, The Tavistock Clinic is recognised and respected as one of the world's leading psychoanalytically-based psychotherapy centres. It became part of the National Health Service in 1948. It is a mental health institution with three principal departments - Child and Family, Adolescent, and Adult - and is also one of Britain's foremost training institutions and a pioneer in infant observation research. The Tavistock Clinic Series, written in a clear and accessible style, makes available the clinical and theoretical work that has been most influential at the Tavistock. Future volumes will examine such topics as anorexia, infant mental health, group work, and work with the elderly.

The systemic model has long been associated with seeing families in family therapy. Systemic practitioners have extended their practice more broadly into the wider domain of human systems, not exclusively focused on families, but applying the systemic approach also to work with individuals and couples as well as to training, consultation and liaison with professionals and agencies. A system is a name given to a set of relationships created between people characterized by a pattern of connectedness over time. Individuals in a system are seen to affect and be affected by each other in what is described as a circular way. This is in contrast to the idea that many hold, that one person affects the other unidirectionally—that is, in a linear fashion. Systemic therapists, however, also recognize that some people in a relationship may have, or be seen to have, more power to influence what happens than others—for example, parents often having more physical strength to impose their wishes on children. Systemic therapists intend to intervene to enable individuals to alter the balance of relationship between them, on the basis that the way the relationships are organized maintains or even creates the problems which are the source of their concern. Problems are not conceptualized as being located within the individual. Working systemically means that it is possible to choose to work, not simply with a family who live together, but to invite all those who are contributing to or have a role in constructing the problem that needs to be addressed: “the problem-determined system” (Anderson, Goolishian, & Windermere, 1986). The systemic approach is a crucial aspect of working with families who foster and adopt and with the professionals and agencies involved in their care. It offers a framework for understanding and intervening in the inter-relationships between the complex systems created for caring for children outside their birth families. Practitioners are seen as part of a new “co-created” system, which is formed between themselves and the families and other professional participants in the course of the conversations that they have together. The therapist actively participates in the creation of the story which emerges in the session, through questions which are asked or which remain unasked and by the interventions which are made. This contrasts with an idea that is sometimes held, that it is possible for therapists to act on the family from an outside, external position without being affected themselves.

Psychoanalytic child and adolescent psychotherapy as practised at the Tavistock Clinic has two main roots: one is its psychoanalytic theoretical base; the second is its base in the observation of infants and young children. These come together in practice with children and families. This chapter is to show the particular relevance of the theoretical base in our work with looked-after and adopted children and in our participation in the work of a multidisciplinary based team. The same frameworks inform work with both foster carers and parents.

Freud developed a new theory of man and of mind at the end of the nineteenth and early twentieth centuries. His new “science” challenged the prevailing views of mind, motivation, and the innocence of children. A medical, neurological model, it described impulse-driven behaviour in a quantitative way. Later he developed a formulation of mind, in which man is driven by conflict between the life and death instincts, under the influence of ego, id, and superego. He described transference and countertransference. It was left to his followers to elaborate his theories into more finely honed working clinical tools.

Our work often brings us into contact with children whose parents were unable to care for them, leaving others to assume this duty. They have often endured multiple separations and losses. It was children like these who first inspired John Bowlby to devote his career to studying and understanding the impact upon children of maternal deprivation. In a report for the nascent World Health Organization, Bowlby commented on how mental health depends on children receiving continuous care, from which both mother—or mother-substitute—and child derive an enduring sense of joy (Bowlby, 1951). During the 1950s, at the Child and Family Department he helped to establish at the Tavistock Clinic, Bowlby convened a study group aimed at elucidating the importance of the parent–child relationship. Among his many colleagues was Mary Ainsworth. She conducted longitudinal studies of infants and their mothers, which identified sensitive and responsive care as the vital ingredient in promoting secure or “healthy” infant–parent relationships and, in turn, a solid sense of self within the child that would launch him towards trusting relations with others, and a sense of competence in pursuing cognitive and social goals. Bowlby drew on Ainsworth’s developmental research, cognitive psychology, control theory, and evolutionary theory to advance a theory of attachment in three volumes, Attachment (1969), Separation (1973), and Loss (1980).

In the last decade neuroscience and developmental research have-provided convincing evidence about the impact of early experience on later development, and in particular of the impact of trauma and neglect on the developing brains of young children. This has become a powerful explanatory tool to be used alongside other bodies of thought, such as attachment theory and both psychoanalytic and systemic therapy, to make sense of the plight of many children who have been adopted or fostered and their families. We now have neu-roscientific explanations for why such children provide such a huge challenge to their carers and the systems around them, for why all too commonly we see in these children symptoms such as aggressive and self-destructive behaviour, being impervious to ordinary affectionate care, impulsiveness, the inability to regulate emotions, and the other signs described all too clearly in this book.

Much has changed since the early days of psychoanalysis, when it was believed that traumatic early experiences, such as of sexual abuse, were repressed, leading to all manner of malevolent symptoms that were cured by helping people to remember the traumatic episodes. We have since discovered that cure and changing symptoms are not so simple, and that the basic explanations used in those days were somewhat off the mark. In particular, our understanding of the fine details of how early experience affects children is much more advanced, as is our understanding of how certain experiences affect different parts of the brain. More is now known about how different areas of the brain link up, and how some brain functions may be more to the fore at different points in a child’s life. We know now, for example, that levels of stress in a mother as early as pregnancy affect the unborn child (Field, 2004), and that the stress hormone, cortisol, released by pregnant mothers, will cross the placenta and impact on the developing foetus. We know that infants who have consistent and attuned caregiving develop the ability to “self-regulate”, whereas experiences of either neglect or trauma might not be consciously remembered but will affect not only behaviours and attitudes, but also the very structure of the brain as well as the HPA axis, a central part of the neuroendocrine system that controls reactions to stress, particularly through the releases of hormones. This is a system that humans share with many organisms from way back in evolutionary history.

The work of a specialist multidisciplinary CAMHS team assessing and treating looked-after and adopted children necessitates in almost all cases consideration of whether a diagnosable mental health disorder is present, especially given present knowledge that suggests that this is so for almost 50% of looked-after children (Melt-zer et al., 2003). The well-known, strongly expressed antagonism to the making of diagnoses is based on a belief that damage is done to children by the process of labelling and a fear of the stigma associated with mental illness. However, the dangers of disadvantaging children and young people, their parents and carers, and the professional network by the failure to recognize a significant mental health problem outweighs these concerns. There is therefore a clear role for a child and adolescent psychiatrist in participating in the diagnostic assessment process undertaken by the multidisciplinary team. In addition to the significant level of mental health difficulties in this group of looked-after and adopted children, they also are more likely to have physical disorders, including epilepsy, speech and language disorders, developmental delays due to both organic and environmental factors, such as enuresis, conditions such as foetal alcohol syndrome, and other forms of learning difficulties (Meltzer et al., 2003). There is, therefore, an additional role for the psychiatrist in identifying physical health problems and referring young people, if needed, for investigation and further assessment by a paediatrician or, where appropriate, for a psychological assessment.

When placements are being considered for children, or indeed when the functioning of a child in care is a cause for concern, the multidisciplinary team will often turn to the psychologist for a view about this. This chapter briefly outlines the range of assessments that are undertaken by psychologists and underlines the importance of drawing together information about the child from different sources and perspectives. The field of psychological assessment is wide. This chapter draws attention to the complexities involved in the process of assessment rather than providing a detailed account of the assessment tools used.

Both clinical and educational psychologists are trained to undertake psychological assessments. The main difference between them is that educational psychologists tend to focus on the child in an educational setting (although they do always take into account a child’s background or home environment), whereas clinical psychologists are trained in understanding emotional, learning, and behavioural experience across the age range, through childhood to adulthood and old age. Clinical psychologists who work with looked-after children tend to specialize in this area through further training and clinical experience, as is the case with the psychologists attached to the Tavistock Clinic Fostering and Adoption team.

When I go to collect 6-year-old Ryan from the waiting-room, I am struck by a picture of a boy in a real transition. He is sitting next to his social worker, surrounded by a pile of luggage. When he sees me, Ryan picks up a duffel bag, which he drags along the corridors to the therapy room. Having arrived in the room, he tips up the bag, and his toys spill out onto the floor—first some soft toys, and then cars and games. I feel that he is showing me his most precious possessions, all that he has at this moment. He hands me one of his soft toys—I find I am glad to hold onto its softness at this poignant moment. Ryan starts to play with his cars, telling me about the ones that are his best. Gradually I talk to him about how he seems to be carrying his luggage with him today; that I know he has come from one foster home and is moving to another after he has seen me. He tells me that he liked where he was, it was quiet there. He pauses and seems to reflect. I say that it sounds as if it was a place he liked to be, and it was perhaps quite hard to leave. He nods in agreement.

This chapter outlines the basic principles of cognitive behaviour therapy (CBT) and how CBT can be adapted for children who have been fostered or adopted and their families. Children are usually placed into care either because their families of origin have decided that they cannot parent them or, more commonly, because outside agencies have concerns about the quality of care provided to them. Children who are looked after by others have, by definition, experienced trauma. This trauma has often been considerable and over a long period of time. Looked-after children can present a very real challenge for psychological treatment. They are likely to have undergone multiple traumas such as emotional or physical abuse and then the loss of their family and home (even though relationships may have been difficult) and often multiple placements. They can be extremely emotionally damaged by their difficult life experiences and sometimes also by the subsequent events related to moving into care.

One of the risks of adopting children in care is that they may perpetuate their deprivation by rejecting the loving care offered them. Clinical experience shows that when this happens, it can sometimes be possible to facilitate children’s attachment to their new parents by involving them in individual therapy.

This chapter aims to describe the difficulties inherent for these deprived and rejected children in making new attachments and to consider how a new relationship to a psychotherapist may help these children to take the risk. Concepts from psychoanalysis and from attachment theory are used to understand the therapeutic process.

In order to explore these issues, I bring examples from the psychotherapy of two children—Max and Pauline—who had each been adopted at the age of 4 years but who had not bonded with their respective adoptive parents.

When they started therapy, Max was 9 years old, and Pauline was 14.

The early histories of these two children were typical of children placed in late adoption and do not need for present purposes to be individually specified. Enough to say that after two or three years in their birth families, where they suffered both abuse and neglect, they experienced several foster home placements before joining their adoptive families. Both sets of adoptive parents were caring, concerned, and thoughtful people who supposed, as many adoptive parents do, that they could undo the adverse effects of their children’s early experiences within a year or two.

The idea of belonging somewhere is an ordinary and fundamental building-block of a sense of personal identity. Everyday events remind us of this: a lost child wandering around a shopping centre or park gets asked “Who do you belong to?” The assumption is that the answer will be the clue to who the child is—the son, or daughter, or brother, or sister, or grandchild of particular individuals. A child’s belongings are those objects that characteristically define him as a recognizable person: his coat, shoes, school bag, and so on. The somewhere that we belong starts off as our family of origin in which we are accorded a place defined by relationships. Around this will be concentric circles in which we belong in some fashion to wider social groups: extended family, school, local community, city, region, country. Recall the addresses many primary school-aged children like to create for themselves, which record all the layers of belonging, ending up with “The World” and “The Universe”. In a religious conception we all belong in God’s family and are protected by His all-seeing eye. Humanly, the sense of belonging also resides in the recognition of oneself as part of the sentient group by others. Children who cannot be brought up in their families of origin suffer a basic disruption in this sense of membership, of knowing where they belong.

This chapter addresses the gaps between the hopes and expectations of adoption and the often painful realities of the experience, and how we have helped families to bridge them. This is because adoption is a complex process, and the hopes and expectations of each person involved in it are invariably different. Though many remain unvoiced and some are only partially conscious, they are still difficult to relinquish. Most people know that adoption today is a particularly risky enterprise because it sets out to remedy earlier failures and experiences of loss and trauma by putting together children and adults who have only a nominal opportunity of choosing each other and no previous experience of living together. Their reactions to this experience can be explosive and leave everyone shaken, not least the social workers who carry heavy responsibility for the outcome.

There is great need for families and professionals to have access to a team separate from those that make the placements but familiar with the demands of the situation, where there are opportunities to work out what may be going on, the adaptations that are necessary, and where feelings may be expressed and understood. There is frequently little opportunity for the latter because, as Lear has said (1998), “there is a wish to ignore the complexity, depth and darkness of human life... there is a wish in everybody to ignore pain”. If something as challenging as building a family through adoption is to have any chance of success, families and those who work with them must be open to feelings that are often hidden and emerge in unexpected ways. The defences of denial and pretence do not work.

Children are often described as “belonging” to their families. We talk about “our” children and like to think that they will become the people we want them to be. Adoptive families struggle to find a way to “belong” to one another within a context of other belongings. This chapter discusses work with families after adoption and the dilemmas they encounter in finding a way to “belong”.

During my professional life I have worked with adoptive families and children through the process of assessment, placement, and breakdown, with adopted adults referred by their GP and, as a family therapist at the Tavistock Clinic, with families after adoption. I draw on these experiences and in particular the work undertaken to help families develop a way of living together that fits well enough for each member of the family.

Much of our work is with families who have adopted children removed from their birth families following concerns about parenting, or with families who have adopted children from overseas. In our multidisciplinary team we work initially with all parts of the system: the family together, the parents on their own, the young person and/ or siblings and involved professionals, such as social workers and teachers, where appropriate. The most common themes in our work are the influence of the past on the present family predicament, of loss and of children’s loyalty to their family of origin, all of which may never previously have been discussed, even with a professional.

There has been a marked change over the last few years in the number of referrals to our team for children placed with relatives and friends. These have come to represent between 12.5% and 26% of our total referrals over the three years to 2005. In most of the kinship cases we see, the major issue that has led to the children needing an alternative placement has been parental drug and/or alcohol misuse. There are often accompanying issues of adult mental health difficulties, domestic violence, child abuse, and neglect. Some kinship arrangements have come about because of forced migration due to war, conflicts, and persecution that have split families apart. The families who come to our service are drawn from a wide ethnic, racial, and class background. This picture reflects the American experience (McFadden, 1998). There is a body of research into kinship care from both the United States and the United Kingdom confirming that kinship carers overall are older, less well off, have poorer health, and are less supported than other foster carers (Broad, 2001; McFadden, 1998; Sykes, Sinclair, Gibbs, & Wilson, 2002).

In this chapter we describe parenting training groups that we have offered alongside other clinical work to families referred to the specialist Fostering, Adoption and Kinship Care team at the Tavistock Clinic. We consider what is special about these groups and the various additional issues that needed to be addressed because of the particular needs and demands of adoptive, foster, and kinship families. We explore some of our ideas about the cognitive–behavioural approaches of the group programme we have followed and how these fit with other core theoretical models and trainings.

Many of the families we work with come to us in a state of exhaustion and despair. Some of their struggles are undoubtedly shared by parents in more ordinary circumstances. However, for adoptive, foster, and kinship families, the difficulties in managing the daily tasks of parenting and the levels of challenging, disturbing, and oppositional behaviour in the children for whom they care may be extreme. Parents and carers may be feeling defeated and in touch with sides of themselves they just did not know existed, which can be very disturbing for them. As in many fields, offering groups to people who have a common presenting difficulty may be a helpful experience that enables them to begin to feel less isolated and more empowered to deal with problems and to connect with their strengths. For this reason, and in response to a growing body of research into the effectiveness of some parenting programmes, we decided to train in and then offer some groups to parents seen by our service. The aim was to offer a structured parenting programme and an opportunity for parents and carers to come together with others in similar circumstances.

Throughout this book, it has been made clear by many authors that work in fostering, adoption, and kinship care, in common with many aspects of mental health care, is essentially of a multi-systemic nature. In chapter 17 I paraphrase Winnicott by saying that “there is no such thing as a looked-after or adopted child”, meaning that whether or not contact with the birth family is enacted in practice, the original family is always an integral part of the child’s existence and is looked after or adopted along with the child. In addition, however, a significant number of professionals are also involved in the lives of these children, young people, and their carers, with differing responsibilities and for varying periods of time. The practitioners belong to a range of agencies, including health, social care, education, youth justice, police, and the legal system, each with their own ethos and beliefs about their role, preferred outcome, and authority for decision making on behalf of the children and their families. It is rarely possible to work with a child or family effectively without involving their network. Furthermore, it is often the case that the problems being presented are most appropriately addressed by working with the professionals, both with and sometimes without the members of the family. This is because the difficulties may be located in the wider system as much as they are being enacted within the family (see Emanuel, chapter 18).

This chapter sets out to describe how the containment provided by the consultation process can help professionals to develop a coherent narrative about the experience of families for whom they are responsible. These children and their parents are often psychically disabled by the traumatic experiences they have endured, and they have only a fragmented, partial, or distorted sense of what has happened to them or what is happening in their day-to-day lives—in-deed, in all of their relationships. They and the professionals who work with them can become blind to and defended against knowing what is going on because it is so painful. Consultation can provide a mental space in which they can begin to allow themselves to see the damage that has been done and continues to be done, so that they can work together more realistically to counteract this and towards achieving change.

Consultation forms a substantial part of the work done by the Fostering and Adoption team at the Tavistock. It is generally sought when professionals disagree about decisions that have to be made. In this chapter I illustrate two situations and the consultation we provided by describing aspects of work with families who are amalgamations of many we have seen. I first explore the dilemmas that arise when there are disagreements over whether children should remain in worrying birth families or should be removed from them, and the role that consultation can play in these circumstances. I then look at the role consultation can play when there are difficulties with finding permanent placements for children who have been removed from abusive families and have become increasingly abusive themselves. Other consultations are described in this book, for example consultations about contact. Most consultations are brief. The situations I describe in this chapter, however, have required us to provide consultation over prolonged periods of time. This is perhaps because of the sheer difficulty of the tasks expected of social workers, and also because of the rapidly changing nature of the care system, described by Lindsey in the introduction to this book.

Working with questions relating to the issue of contact with birth families is an integral part of therapeutic work with children who are fostered, adopted, or in kinship care. The distinctions between the different forms of care are not always the most relevant factors for the child, birth family, and substitute carers, despite the differences in the legal framework that play a part in determining how much and whether contact occurs. The concept of openness is more important here, regarding both open communication and structural openness to actual contact. Therefore, in this chapter, the material relates to contact in all these different contexts. It is self-evident that the meaning and purpose of contact varies depending on the type of care episode, with whom the contact takes place, and its form. Contact is not an all-or-nothing concept. The infinite variations reflect the unique pattern formed by each family constellation. Hence, there are no hard and fast rules for determining what is appropriate in any one situation, and as relationships develop over time, there are changes in the need and abilities of those involved to participate in contact arrangements. Contact can be defined as the symbolic representation of the young person’s relationship with, at least, two sets of families. The type of contact, whether it is face-to-face or letter-box and all the many variations, carries a message about the nature of the relationship. This varies from conveying contact as a step in the process to rehabilitation with the birth family to a loving and lifelong concern and interest in the child who is being brought up by others. It is a socially constructed event in which each in the triad of child, birth family, and substitute carers plays a crucial part, and success depends on the ability of each party to contribute positively to the process. Furthermore, since most of the children and young people with whom a service like ours is involved are placed from care, the ongoing attitude, role, and availability of social work services can be pivotal in ensuring the safety and success of contact arrangements.

In this chapter I describe how the trauma and disturbance associated with severe deprivation and abuse by children and families can impact on the professionals involved in their care, interfering with their capacity to think about and provide containment for the children and their carers and thereby compounding their deprivation. The chapter title refers to the “double deprivation” as originally described by Henry (1974) together with a third level of deprivation, which can occur within the organizational setting. The first deprivation is inflicted by external circumstances and is out of the child’s control; the second derives from internal sources as the child develops “crippling defences” (Henry, 1974) that prevent him from making use of subsequent offers of support, for example, by foster carers or adoptive parents (or a psychotherapist). The third refers to the ways in which, as Britton (1981) writes, “ the profoundly disturbing primitive mechanisms and defences against anxiety” used by children and families get “re-enacted” in the system by care professionals, who are the recipients of powerful projections. These defences, including unconscious attacks on linking, can interfere with professionals’ capacity to think clearly or make use of outside help with their overwhelming caseloads. A social services department may then replicate these children’s original experience of neglect, allowing them to fall through a hole in the “net”work. This form of “re-enactment” as a substitute for a thoughtful response by professionals within an organization, combined with the “double deprivation” described by Henry, can result in a “triple deprivation” for children within the care system. (The concept of “triple deprivation” was originally described by Sutton, 1991.)